2024 ACC ECDP on Post-Stroke Arrhythmia Monitoring: Key Points
The following are key points to remember from a 2024 American College of Cardiology (ACC) expert consensus decision pathway (ECDP) on practical approaches for arrhythmia monitoring after stroke:
- Stroke is a leading cause of death and disability worldwide. Atrial fibrillation (AF) is the most common arrhythmia that adults experience. AF increases the risk of stroke approximately five-fold. Detection of AF following stroke has significant implications on treatment decisions.
- For patients with AF-related ischemic stroke, the primary treatment choice includes anticoagulation therapy. However, patients experiencing ischemic stroke without detectable AF are typically treated with antiplatelet therapy.
- Traditional methods of AF diagnosis, including brief electrocardiogram (ECG) recordings, often fall short in capturing transient AF. Longer duration of monitoring can increase the rate of AF detection. But the longer the time interval between the ischemic stroke and the detected AF episode decreases the likelihood of AF as a proximal cause of the prior event.
- Various technologies have been developed to identify AF, including continuous or intermittent ambulatory ECG monitors. There are also medical-grade monitors (typically electrical activity monitoring) and consumer-grade monitors (either electrical activity monitoring or photoplethysmography).
- Arrhythmia monitoring after a stroke requires three important steps. First, a multidisciplinary evaluation should be undertaken to identify potential mechanism for stroke. Second, risk assessment is performed to determine the likelihood that a cardiac arrhythmia played a role in the stroke (or future stroke). Third, an optimal monitoring strategy should be selected to be accurate, practical, and establish follow-up.
- For patients with a high-risk cardioembolic source (including those with AF detected before the stroke), long-term anticoagulation is recommended. Cardiac monitoring is only needed if a patient no longer desires or requires anticoagulation therapy or if there is concern for another arrhythmia (e.g., bradycardia, pauses).
- For patients with large- or small-vessel disease, long-term antiplatelet therapy is recommended. Cardiac monitoring may be considered, preferably for ≥14 days. An implanted loop recorder can be considered in high-risk patients.
- For patients with an unclear source of their stroke (i.e., cryptogenic), long-term antiplatelet therapy is recommended. Cardiac monitoring is recommended for ≥14 days, especially if they are a candidate for anticoagulation therapy. An implantable loop recorder may be used as the initial strategy in select high-risk patients.
- For patients in whom arrhythmia monitoring detects >5 minutes of AF, anticoagulation is likely recommended. This is particularly true if their CHA2DS2-VASc score is ≥3. For those with no AF, continuing antiplatelet therapy is recommended.
- In patients with stroke from a presumed cardioembolic origin, there is a limited role for rhythm monitoring given that anticoagulation is presumed necessary. Monitoring should only be considered if there is discussion around stopping anticoagulation or other treatments based on rhythm detection.
- Consumer devices have important limitations for AF detection, notably requiring direct skin contact for accurate reading. Those equipped with ECG capabilities are superior to those using photoplethysmography alone. Even when ECG technology is available, it requires active measurement by the wearer and is not “continuous” as with the medical-grade devices.
- Consumer devices may be useful in patients who cannot tolerate medical-grade devices and refuse an implantable device. They also are useful in patients who have clearly identifiable symptoms. However, increased burden on the health care system and disparities in access are key limitations to consumer devices.
